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ATTACHMENT 2 <br /> SITE IDENTIFICATION FORM <br /> (Attach additional description or explanation as needed) <br /> INITIAL I.D. (Y/N): Y FOLLOW-UP INVESTIGATION (Y/N): <br /> SITE INFORMATION <br /> SITE NAME: M c.�o,41� -:Fj&k" Jr „ _ �)i5sal !!Eii�-e <br /> AKA: <br /> SWIS It. COUNTY: PARCEL #(s): t 2cj -08 - 0.9 <br /> LOCATION: V� Bs,j d Q H E• , j g N • m j) F t._t <br /> (Include Location or Quad. Map With Township, Range and Section, and Parcel Map) <br /> LAND OWNER(s): <br /> ADDRESS: Q. Q oX D <br /> CITY:', STATE:G,_ZIP: q912n PH <br /> TYPES OF WASTE: INERT, RES., COM., INDUST., HAZ. LIQUID <br /> SITE TYPE: ILLEGAL DUMPING, LANDFILL, BURN DUMP, TRE ENT UNIT <br /> DISPOSAL AREA (ACRE): SWFP DATE: WDR NUMBER: - <br /> DATES OF OPERATIONS: CLOSURE APPROVED BY: <br /> LAND USE ON OR WITHIN 12W FT i OF WASTE BOUNDARY <br /> RURAL: Y YES NO <br /> RESIDENTIAL: YES dUYES <br /> COMMERCIAL: _ Y <br /> INDUSTRIAL: (_YES)NO YES NO <br /> ENVIRONMENTAL SENSITIVE: 571_=_qNO yi=oz din <br /> WATER SUPPLY WELLS: _ r I.-F'_ 'W Y �°N I r'_ <br /> SURFACE WATER BODIES: N <br /> INHABITABLE STRUCTURES: YES V NO <br /> ENCLOSED STRUCTURES: YES NO_ <br /> PLANNED IMPROVEMENTS: YE N <br /> OBSERVATIONS <br /> DATE OF FIELD VISIT: SIG.CHANGE SINCE rST VISIT? (Y/N/NA) <br /> SURFACE CONDITION: %I _%L, <br /> LANDFILL GAS: Np, I— n_-Lo V <br /> LEACHATE: o <br /> OTHER: <br /> RECOMMENDATION <br /> EMERGENCY RESPONSE: �D <br /> OTHER (e.g. small scale Illegal dumping that warrants removal): <br /> REASSESS SITE? (Y/N/NA): �J NO FURTHER ACTION? (D PRIORITY Y/N): <br /> PRIORITY FOR SITE ASSESSMENT (High/Med/Low): <br /> PREPARED BY: DATE: L4 -2 <br /> CIWMB APPROVAL: C&R BRANCH COMPLIANCE <br /> CIWMB Closure and Remediation Branch (1/25/93) <br />